Eligibility Verifications for Medicaid


How to Run the Report

Eligibility verification are requests sent to NC Tracks to verify a patient’s eligibility for one month.   Every patient’s eligibility is either approved or denied on a calendar month basis.   It is pertinent that eligibility is verified monthly, as beneficiaries lose benefits or change insurance.  This ALL affects billing.

Patients that will be excluded from the report are: patients without a sex entered on the referral, patients with a discharge date before the From date on the report, status of cancelled or Referred, not admitted - unless the checkbox "Include Referred but Not Admitted" is checked. 

We recommend using the following reports before creating the eligibility.  The reports will help verify that all required patient information is complete.  From Barnestorm Office click on Reports > Audit, use reports 07.01 and 07.02.

To Create Medicaid Eligibility Verifications file:

This step creates the electronic file to send to NC Tracks.  You are also able to print the report of patients that will be sent for review. 

 

To Send The Eligibility Transmission - file type 270:

This step transmits the electronic file to NC Tracks.

To Receive Medicaid’s Response:

This step will receive a response file back to confirm that they have received the file without any issues.  

To Receive Medicaid's Verification Report

This step will receive the verification report from Medicaid so that you can print it from Barnestorm.

To Print the Eligibility Verification - file type 271:

How to Read the Report

All:

Will print all three options; Problems Only, Carolina Access Only.

Problems Only:

        ** Inactive means that patient does not have Medicaid for the selected month of the report.

        ** Pvt Ins will let you know if the patient also has a private insurance policy.  Nothing else needs done unless the patient is being billed for skilled services, which may require a denial from the insurance first. 

Carolina Access Only:

        OK if the eligibility status is OK

        MQ Medicare Premium Only = Medicaid will not pay claims, they only pay the Medicare Part B insurance premium.

        DE Deductible = This patient must meet a monthly deductible before Medicaid begins paying claims.

        EM ER Only = Medicaid pays for Emergency Room only.

        HC Health Choice = This patient is enrolled in Health Choice - children under 21 - and must be billed to the Health Choice provider.

        Will give the date of the month for eligibility.

        Including the Carolina Access Provider number.

              Will show the name of the Carolina Access Provider.

        ****MISSING**** means that no CA# was assigned for that month.

        ****MISSING**** Updated to means that the CA# was missing in referral but the description that came back in the EDI file is an exact match for one of the descriptions in the cross-reference file, Billing > Other > Carolina Access to NPI CrossReference, so the referral screen was updated with the matching CA#.

       If the top and bottom line have slightly different names for Carolina Access Provider = The top line is what came back in the EDI file; the second line is what the CA# cross-reference has, Billing > Other > Carolina Access to NPI CrossReference. 


Medicare Missing D9 - NC Only:

This report checks to see if the patient has Medicare.  If so, it will check to see if the patient has the condition code D9 setup in the Referral > Payer > Extra Billing Info screen. 

If the patient has Medicare but is not homebound, then you have to bill Medicaid and use the D9 condition code on the claim to indicate that Medicare is not the primary payer for that service. 

If you admit a homebound patient but only confirmed the Medicaid, and didn’t know about Medicare, then you will need to switch the payers, from Referral > Payer, to be Medicare standard.  

EDS does not use the same patient information database to verify eligibility that they use to pay claims.  That's why claims for a patient can be paid, and the eligibility returns a response of Patient Unknown.  If the spelling of the first name is different, if the date of birth doesn't match what's in the eligibility system, these can cause a Patient Unknown response.  

Medicaid eligibility only uses the above processes. The Check Eligibility in Referral is only for Zirmed (Medicare).